Inspiratory rales were present, consistent with pulmonary edema, and his skin was cold and clammy. Sequential ECGs and serum levels of cardiac enzymes (creatine phosphokinase and lactate dehydrogenase) suggested a left ventricular wall myocardial infarction. Pulmonary capillary wedge pressure, obtained during cardiac catheterization, was 30 mm Hg (normal, 5 mm Hg). His ejection fraction, measured with two-dimensional echocardiography, was 0.35 (normal, 0.55).